Medical Journal of Babylon

The equal distribution of the health workforce has been identified as one of the key determinants for the attainment of healthrelated
goals. The purpose of the current review is to identify the existing practices of rural medical education and to recommend
strategies for the strengthening of the same. An extensive search of all materials related to the topic was carried out on the PubMed
search engine. Keywords used in the search include rural medical education and undergraduate medical curriculum in the title alone
(viz. rural medical education [ti]; rural [ti] AND undergraduate medical curriculum [ti]). Relevant research articles focusing on rural
medical education and undergraduate medical curriculum published in the period 2002–2020 were included in the review. A total of
21 studies similar to the current study objectives were identified initially, and those were screened for eligibility. However, two articles
were excluded owing to the unavailability of the complete version of the articles. In the current review, the articles published in only
the English language were enrolled for the review. Overall, 19 articles were selected based on the suitability with the current review
objectives. In general, the people living in rural settings are a vulnerable section, as they have access to the limited resources and healthcare
facilities. Thus, from the perspective of the rural population, the exposure of medical students to rural settings simultaneously
enhances their accessibility to health-care services, which, in turn, takes us forward toward the attainment of universal health coverage.
In conclusion, the provision of medical education to the undergraduate students in rural settings is the need of the hour both for
producing a competent medical graduate and for meeting the health-related needs of the vulnerable rural population. It becomes the
responsibility of the medical institutions to ensure that all the medical students are posted in rural settings as a part of their training
and are encouraged to serve the rural population.

The coronavirus disease-2019 (COVID-19) pandemic has thrown health systems indiscriminately across the globe into turmoil. The
important route for the spread of COVID-19 is through aerosolized droplets that are expelled at the time of coughing, sneezing, or
breathing, but there are also concerns for possible airborne transmission. COVID-19 pandemic has placed an unprecedented stress
on the health-care system. Sudden increase in demand and limited availability of personal protective equipment (PPE) is making risks
on health-care workers, which hamper their ability for effective management of the patients. Several health-care workers are dying in
this global outbreak because of the improper protective measures during performing the high-risk procedures. Limited availability
of the vaccine to health-care workers in all parts of the world and inadequate supply of proper therapeutic agents, such as personal
protective measures, among health-care workers for restricting the COVID-19 spread are an important requirement. Regardless of
the debate among the medical community for the use of PPE, a greater number of countries in the world are moving ahead with
recommendations or mandates for using PPE in clinical interventions or caring for the COVID-19 patients. Some have attributed the
death of health-care workers to inadequate supply of the PPE. However, there are some concerns about the improper use of PPE by
the health-care workers. Policy makers, government, and health experts have increased the importance of manufacturing more PPE
for the safety of the health-care professionals particularly frontline workers for COVID-19 patients. This review article provides an
overview of PPE for frontline health-care workers in the COVID-19 pandemic.

The making of a medical professional is a complex task and essentially requires a combination of a number of activities. The present
review was carried out to explore the implementation of attitude, ethics and communication (AETCOM) module related teaching
and assessment in medical colleges in Indian settings. An extensive search of all materials related to the topic was carried out in the
PubMed search engine, and a total of 28 articles were selected based on the suitability with the current review objectives and analyzed.
Keywords used in the search include attitude, ethics communication, medical students, and medical education in the title alone. In
order to bridge this gap, the regulatory body has introduced the AETCOM module in the undergraduate curriculum. The topics in
the AETCOM have been divided into different modules, which gradually becomes complex as the students move from the first phase
to the subsequent phases. The assessment of the AETCOM competencies can be done through the use of a wide range of methods.
However, the successful implementation of the same will immensely depend on the faculty development programs. To conclude, in
order to accomplish the national vision to produce a competent graduate who can meet the health-care needs of the society, the
phase-wise introduction of AETCOM module is a significant step. This calls for the need to adopt a systematic approach to effectively
schedule and cover the assigned topics, thereby guiding the students on the path toward becoming community physicians

Chitosan is a biopolymer chitin derivative discovered in 1811 by Henri Braconnot, and it was first used in 1985 by Charles Rouget.
It is produced via the deacetylation of chitin (the natural component of the arthropods exoskeletons and the fungal cell wall). The
unique solubility and the chemical and biological characterization of chitosan attracted more scientific and industrial attention,
specifically in the past 20 years. Its properties depend on the degree of deacetylation and its molecular weight. Therefore, recently,
different forms of chitosan (solutions, suspension, gels/hydrogels, sponges, microparticles/nanoparticles, membranes and films, fibers/
nanofibers) and its derivatives have been used in many fields. It has a wide range of applications in various fields, such as medicine,
industry, agriculture, and commercial research. Medicinally, because of its biocompatibility, biodegradability, nontoxicity, natural
origin, and similarity with human macromolecules, chitosan is widely used in pharmaceutical applications, antimicrobial applications,
gene delivery, gene therapy, wound healing and burns, regenerative medicine, tissue engineering, cancer applications, dermatology,
ophthalmology, dentistry, biosensors, as well as bioimaging, support for immobilized enzymes, and veterinary medicine. In this review,
some medicinal applications of chitosan will be highlighted.

Background: Acquired immune deficiency syndrome (AIDS) is a disease affecting the human immune system; it is caused by a virus
that reduces the effectiveness of the immune system of the body to the extent that it is no longer able to fight a simple infection. The
health promotion program is an important option in preventing the disease by raising the level of knowledge and information of the
individual. Objectives: To determine the level of the pregnant women’s knowledge about AIDS as well as to identify the effectiveness
of the health promotion program on the knowledge and information of the pregnant women toward the disease and the relationship
with some relevant variables. Materials and Methods: A cross-sectional study was conducted in Babylon/Al-Hashimiya district from
September 20, 2020 to December 30, 2020. Data were collected from five health centers at Al-Hashimiya Health Sector (health centers
in Al-Madhatiya, Khakan, Al-Qassim, Al-Ghazalli, and Al-Awadil), by using a special questionnaire designed for this purpose. Simple
random sampling was used for the study; 300 pregnant women served as the participants attending health centers. Results: Result
shows the majority of the pregnant women (123, 41%) were registered at age 25–29 years. With regard to education, 111 (37%) of the
participants in the study sample were at secondary level of education, and about 202 (67.3%) of the participants were housewives.
Regarding residency, 169 (56.3%) of the women participants were reported to be in urban areas. In addition, an analysis of the results
by the “chi-square” test had reported a high significant association (P ≤ 0.01) between pregnant women’s knowledge and basic sources
of the information and the knowledge during the pretest and posttest period, with some factors related to the effectiveness of the
health promotion program being achieved by success in the field of health promotion (15.7%) during two periods. Conclusions: In the
present study, knowledge of pregnant women about HIV/AIDS was intermediate at (pretest) period. Whereas, during the (posttest)
period, their knowledge was increased to high levels.

Background: SARS-CoV-2, a newly emergent virus which is related to SARS-CoV, caused the pandemic of COVID-19 in China to the
world. Objective: The aim of this study was to describe the basic epidemiological and clinical features of confirmed COVID-19 cases
in Babel Governorate and to find out the comorbidities and risk factors of severity of COVID-19 infection. Materials and Methods:
This is an observational, descriptive, cross-sectional study, conducted on a convenient sample of 222 participants selected from five
referral district hospitals in Babel Governorate, over the period from May 12, 2020 to August 22, 2020. A structured questionnaire
was used to collect data and to interview patients. Data were analyzed by using SPSS version 23. Results: The mean age ± SD was
(49.92 ± 14.062 years) ranged between 10 and 89 years (median 50 years) with male predominance. The majority of the participants
had comorbid conditions, including hypertension, diabetes mellitus, heart disease, and asthma. Fever constituted (85%) of symptoms
followed mainly by persistent cough, loss of appetite, breathing difficulty, and diarrhea [(81%), (56.9%), (55%), and (42.3%)],
respectively. In addition, 33.34% of the patients have SpO2 ≤ 92%, and two of the three patients have mild-to-moderate symptoms,
and one-third considered either severe or critically ill cases of COVID-19. Conclusion: Elderly people with comorbidities are the most
vulnerable to the infection of COVID-19. Smoking, obesity, traveling history, and working in healthcare facilities that contain cases
of COVID-19 are risk factors leading to the occurrence of and exposure to COVID-19. People who have low level of education and
are living in rural areas with big families tend to get infected mainly, and this may be due to their poor knowledge about the route of
transmission and the importance of prevention measures.

Objective: The objective of the study was to assess the difference in numbers and nature of otolaryngology outpatient clinic presentation
during the coronavirus disease 2019 (COVID-19) era. Materials and Methods: A retrospective comparative study was performed in a
single hospital (Medina General Hospital); all data were obtained by reviewing outpatient clinic data records for March, April, and
May 2020. The corresponding period from 2019 was also collected for comparison. Results: A total of 551 patients were seen in the
otolaryngology department of the outpatient clinic during the COVID-19 era of March, April, and May 2020, compared to 1837
patients who were seen in the same period of 2019 making around 70% drop in the total number of patients visiting ENT outpatient
clinic during the COVID-19 era of 2020. Conclusion: Fear of getting COVID-19 infection along with enforcement of quarantine
and social distancing resulted in a great drop in the quantity and quality of patients consulting outpatient clinic in Medina General
Hospital during March, April, and May 2020.

Background: Resection of infrapatellar pad of fat (IPPF) is an ordinary step performed in primary total knee joint replacement (TKR)
in approximately 88% to get a clearer field and eases patellar retraction to a side away during the surgical procedure. Objectives: The
aim of this study was to evaluate the preservation versus resection of the IPPF regarding postoperative pain and range of movements
in patients undergoing primary TKR. Materials and Methods: This was a prospective, case series study conducted in Erbil Teaching
Hospital from March 1, 2018 till December 31, 2018. A total of 28 patients who underwent primary TKR were randomly allocated
into two equal groups. In the first group the pad of fat was resected, whereas in the other group the pad of fat was preserved. The
follow-up period of this study was 9 months. Patients of both groups were seen and followed up in the ward in the first 5 days of
admission and seen again at the outpatient clinic at weeks 2, 6, 12, 24, and 36. The anterior knee joint pain and range of movement
were recorded and observed by visual analog scale (VAS) score, knee score, and knee functional score. Results: Twenty-eight patients
who underwent primary TKR were included in this study. Among them, 18 patients were women (64.28%) and 10 were men (35.72%).
The mean age of the patients was 63.42 years ± 4.31 years, ranging from 56 to 71 years. Improved postoperative VAS score of the
IPPF resection group (6.28 ± 0.91) and preserved group (5.92 ± 0.82) were observed (P < 0.045) at the 6 months of follow-up.
Improvement in the degree of flexion observed in the IPPF preservation group over the resected one (P < 0.0060), with either no
statistical differences were noticed of the final Knee Society Scores or the functional scores of the two groups, (62.78 ± 4.91) and
(50.07 ± 5.80) of the IPPF resected group, (64.57 ± 5.54) and (52.14 ± 5.08) of the IPPF preservation group with both scores (P =
0.059 and 0.850), respectively. Conclusions: Preservation over resection of the IPPF during primary TKR decreases the postoperative
anterior knee joint pain. Consequently, no significant changes were observed regarding the knee joint functionality.

Introduction: Breast carcinoma is the most common malignancy in women and it has become a major health problem affecting women
worldwide. In Iraq, breast carcinoma is still a major cause of health morbidity and mortality in women. Axillary lymph node metastasis
is considered the most important factor affecting prognosis and management in patients with breast cancer. Objective: This study aimed
to evaluate lymph node metastasis in cases of primary invasive breast carcinoma and to find if there was any association among lymph
node involvement with type, grade, and tumor stage. Materials and Methods: This was cross-sectional study of 100 female patients with
primary invasive breast carcinoma aged 25–88 years, which collected from the archive of the educational laboratory in Baghdad Medical
City, Baghdad, Iraq from April 2018 to December 2020. Male patients were excluded from this study. Results: A total of 100 patients
were included in this study; all were women with primary invasive breast cancer with different histopathological types (80% of cases were
invasive ductal ca. NOS). The age range of the patients was between 25 and 88 years. A significant correlation was observed between
lymph node stage and tumor pathological stage (tumor size). Conclusions: Most cases of primary invasive breast carcinoma had axillary
lymph nodes metastasis, with a strong correlation between lymph node stage and tumor size. However, no association was found with
tumor grade or tumor type that could be related to the small sample size of this study.

Introduction: Almost one-third of the Lebanese population are active smokers, with limited knowledge about their attitudes toward
existing smoking cessation interventions. This study aims at exploring the facilitators and barriers facing a smoking cessation program
(SCP) in a Lebanese tertiary referral center from the providers’ perspective. Materials and Methods: This is a qualitative study
comprising a focus group discussion (FGD) among five practitioners from the SCP. The data collected were then transcribed and
summarized by coding, simplifying, and transforming the raw data into major themes and subthemes as per the Miles and Huberman
method of organization. Results: Facilitators and barriers fell under three subthemes: (1) participant factors, (2) provider factors, and
(3) system factors. Facilitators included motivation and concerns about health among patients, in addition to increased behavioral
support from providers. Meanwhile, barriers were much predominant and included stress factors and nicotine addiction among
patients, time constraints among providers, lack of an effective referral system, inaccessibility, and unavailability of pharmacotherapy
as well as a pro-smoking environment with weakly enforced tobacco legislation. Conclusion: Our findings implicate the need for
multilevel strategies to help improve smoking cessation interventions. Addressing identified barriers is of paramount importance to
help develop effective, accessible, and culturally specific tobacco treatment.

Background and Objectives: This study aimed to examine the association between the familial generalized joint hypermobility (GJH)
and developmental dysplasia of the hip (DDH) in children. Materials and Methods: All infants and children included in this case
(with DDH)–control study were examined for features of GJH by the revised Beighton’s Test Scale (BTS), provided that they had
no teratogenic or pathological causes of DDH or GJH. Results: Two hundred and eight participants were included in this study:
101 (48.6%) cases and 107 (51.4%) controls; age mean 16.57 [standard deviation (SD) 18.1] months; 61.1% (127) females and 38.9%
(81) males. The odds ratio was 2.1 (95% confidence interval 1.197–3.679). The cases had a higher value of BTS score (mean = 4.7,
SD = 3.015) when compared with the controls (mean = 3.42, SD = 3.448). The difference was statistically significant, but the correlation
coefficient (r) between the study groups and BTS scores was weak (r = 0.194, P = 0.005). The correlation gained slight improvement
by justification of the age to obtain homogeneity between the groups (r = 0.276, P < 0.001), but deteriorated and lost its significance
when the sex was controlled as a confounder (r = 0.121, P = 0.082). There was a gradual increase in the mean BTS score from grade 1
to grade 4 of DDH but without a statistically significant value (r = 0,132, P = 0.128). Conclusion: The familial GJH has a weak positive
correlation with DDH but cannot be considered as a possible risk factor for it.

Subject: This research focuses on the preparation of a new modified selective medium for the primary isolation of Enterococcus faecalis
in pure culture from heavy and clinical sources. Materials and Methods: The modified selective medium was prepared and named as
Enterococcus Jawad (EJ)–Medium. The new medium was prepared by adding 0.4 g of sodium azide, 2 mL of 0.1% crystal violet (CV),
and 60 g of sodium chloride in a liter of Brain-Heart Infusion Agar (BHIA), and the pH of the medium was adjusted to 8.6. The
primary isolation of E. faecalis from heavy bacterial sources and clinical infections was performed by culturing all collected samples
on EJ-medium and comparing them with other approved selective media, such as Azide-BHIA, CV-blood agar, and Enterococcus
selective agar (ESA), to estimate the ability of these media in isolating E. faecalis (during primary isolation) in pure culture. Results:
The results showed that the EJ-medium had a high rate of isolation, 100%, of E. faecalis in pure culture from heavy sources (human
feces and sewage water) and from clinical sources (urine, bedsore, and blood) when compared with other culture media that were
already used for isolation of this organism. The Azide-BHIA and CV-blood agar showed no high purity in an initial isolation of the
organism. Conclusions: From these results, we concluded that the EJ-medium is highly efficient in the primary isolation of E. faecalis
in pure culture by one step from different environmental and clinical sources; thus, it does not need to be diagnosed by classical
methods that are expensive and consume a long time. Since Azide-BHIA, CV-blood agar, and ESA were not exactly selective media
for the isolation of E. faecalis in pure cultures from heavy sources, their use was limited in clinical cases.

Background: Great importance has been attributed to birthweight all over the world because it is considered one of the best predictors
of perinatal survival and a good indicator of life quality. Aims and Objectives: The aim of this study was to determine the risk factors
for low birth weight among term babies in Babil maternity and children teaching hospital. Materials and Methods: This was a crosssectional
study conducted in Babil maternity and children teaching hospital. The study was carried out in the neonatal care unit from
March 1, 2020 to August 31, 2020. Seven hundred and fifty-four term singleton live births were included in the study. All the neonates
were checked for birth weight, and their gestational age was determined from maternal last menstrual period and early (first trimester)
ultrasound examination and New Ballard score. Neonates with normal birth weight were considered as gestationally full term (≥37
weeks) with birth weight 2500–4000 g. Results: Babies with normal birth weight represent 87.9% of the study sample (663 babies).
The number of term neonates with low birth weight was 69/754, with 9.2% and large for gestational age represent 2.9% of the study
sample (22 babies). Low birth weight of 2100–2400 g represents 6.3% of the study sample (47 babies). Low birth weight of 1500–2000 g
represents 2.9% of the study sample (22) babies. Age of mother, residency, family income, maternal education, antenatal care, bad
obstetrical history, illnesses during pregnancy, and parental consanguinity were considered to be risk factors for low birth weight
at P values of 0.05, <0.001, <0.001, <0.001, <0.001, <0.001, 0.001, 0.002, and <0.001, respectively. However, gender of the baby,
parity, and paternal age were not considered to be risk factors. Conclusion: The problem of low birth weight among term babies is
still common in our country. There was a higher incidence of low birth weight among term neonates in the rural areas and in mothers
with low education level and those who live in families with low income. The most common associated risk factors associated with low
birth weight were young age mothers, positive parental consanguinity, bad obstetrical history, and illnesses during pregnancy (e.g.,
hypertension, diabetes mellitus, and urinary tract infection).

Background: Samples for glycated hemoglobin (HbA1c) measurements should be collected in ethylenediaminetetraacetic acid (EDTA)
tubes, and only a few studies were available for the assessment of its measurements by another anticoagulant tube. There are different
methods with different principles for the measurement of HbA1c in addition to high-performance liquid chromatography (HPLC)
standard method, and one of these methods is ion exchange chromatography (IEC) which depends on the charge differences principle.
Aim of the study: The aim is to compare the effect of different anticoagulant additives (EDTA, lithium heparin, and sodium citrate)
on HbA1c value and to compare the results of HbA1c obtained by the IEC method with those by the HPLC method. Materials and
Methods: This case methodology study investigated the effect of different anticoagulant additives on HbA1c values on 40 diabetic
patients and compared the results of HbA1c values between HPLC method and IEC method on another 40 diabetic patients. Results:
The study showed that there were non-significant differences in HbA1c mean values among different types of these anticoagulant
materials and non-significant differences in glycated hemoglobin mean values between the methods of HPLC and IEC, and sensitivity
and specificity for these techniques were 97.3% and 100% and 97.1% and 100%, respectively. Conclusion: This study showed that
HbA1c can be tested with lithium heparin or sodium citrate as an alternative to EDTA tube, and the IEC method can be used as one
of the main methods for the assessment of HbA1c.

Background: Acute lymphoblastic leukemia (ALL) is a heterogeneous disease in which immature lymphoid cells proliferate mostly in
bone marrow, peripheral blood, and other organs. Flow-cytometric immunophenotyping in childhood ALL assists in the diagnosis
and subclassification of B- and T-lineages, as well as predicting outcomes of the disease. CD200 expression has many diagnostic and
potentially prognostic implications in the flow-cytometric evaluation of lymphoid malignancies. Aim of Study: The aim of this study
was to evaluate the expression of CD200, correlate its expression with hematological and clinical parameters, and assess patient’s
response to induction of chemotherapy in the newly diagnosed de novo pediatric B-cell ALL. Materials and Methods: This prospective
cross-sectional study was conducted on 30 pediatric patients (<15 years) with newly diagnosed de novo B-cell ALL. Morphology,
cytochemistry, and flow cytometry (FCM) of the peripheral blood and/or bone marrow were performed for all patients and the patients
were re-evaluated morphologically at day 28 from the start of chemotherapy for assessment of complete remission achievement.
Results: Majority of the patients (80%) had a positive expression of CD200. All patients were in high-risk group and had positive
CD200 expression and majority of the them were responded to induction therapy. Conclusion: CD200 is frequently expressed and
closely related to the high-risk groups; however, it cannot be considered as an independent poor prognostic marker as not all cases with
positive CD200 had low response to induction therapy.

Background: Mature B-cell neoplasms (MBCNs) are a category of disorders with a broad range of clinical manifestations,
pathologic features, and outcomes that share common characteristics. They originate from the B-cell lineage, are clonal, and have the
immunophenotypic and genetic features of mature B-cells. Flow cytometry (FC) is a widely used method for diagnosing suspected
lymphoproliferative disorders in patients with lymphocytosis, lymphadenopathy, and other lymphoproliferative disorders. Aim: To
evaluate the role of FC in confirming the provisional morphologic diagnosis in patients with MBCNs. Materials and Methods: This
is a retrospective; descriptive study conducted on 193 adult patients newly diagnosed with MBCNs; immunophenotypic findings of
the patients were reviewed. The B lymphocytes were identified according to their Side-Scattered/CD19 distribution. Results: Chronic
lymphocytic leukemia (CLL) was the most common subtype (127, 65.9%). Splenomegaly was noted more frequently in hairy cell
leukemia variant cases (85.7%) and hairy cell leukemia cases (75%). The anemia at presentation was the least frequent in CLL (20%).
The CD5+/CD23+ phenotype of CLL was seen in 114 cases (90%); negativity for FMC7 showed high sensitivity (93.7%) and sufficient
specificity (60%) in the diagnosis of CLL. Conclusions: It is difficult to diagnose B-chronic lymphoproliferative disorders solely based
on morphologic findings. Consequently, FC findings combined with clinical, hematologic, and morphologic features can confidently
result in a precise diagnosis.

Background: Neonatal sepsis is one of the major causes of morbidity and mortality in newborns, more so in the developing countries.
Objectives: The aim of this article is to study the role of peripheral smear, to evaluate the usefulness of white blood cell (WBC)
parameters, and to establish the sensitivity and specificity of each parameter for early diagnosis of neonatal septicemia. Materials
and Methods: The prospective study is of 150 neonates admitted and fulfilling the inclusion criteria, over the period of June 2019 to
December 2020, and tests were performed at the Department of Pathology in a tertiary medical college and hospital. Peripheral blood
sample was obtained by venipuncture and the sepsis work-up included routine blood counts and blood culture. Total leucocytes counts
were counted on an automated hematology analyzer. Leishman-stained peripheral blood smears were used for the study. Results:
Based on the clinical findings and laboratory data, neonates were classified into three categories: sepsis (n = 70), probable infection
(n = 50), and no infection (n = 30). The blood culture reports of confirmed sepsis cases reveal the commonest organism as Escherichia
coli, followed by Klebsiella, Pseudomonas, and beta-hemolytic streptococci. Abnormal I:T ratio (≥0.2) shows highest sensitivity (90%)
and specificity (95%). Conclusion: The peripheral smear study is found to be very useful in the early diagnosis of neonatal septicemia
as it can be performed even in a small laboratory without any special equipment and within a short period of time. Among WBC
parameters, the I:T ratio shows highest sensitivity and specificity.

Introduction: Given the lack of studies on tobacco cessation interventions in the Eastern Mediterranean region, this paper presents
findings from a smoking cessation program (SCP) in a tertiary referral center. The aim is to evaluate the predictors, facilitators, and
barriers associated with successful smoking cessation from both participant and provider perspectives. Materials and Methods: A mixedmethod
approach was used. Part 1 was a retrospective cross-sectional quantitative study with a telephone-based survey conducted
on a sample of 47 patients enrolled in the SCP between March 2014 and August 2017. Part 2 was a qualitative study comprising a
focus group discussion among five practitioners from the SCP. Results: Only 37% reported being adherent to the prescribed treatment
and 74.5% reported receiving behavioral counseling. In the multivariate logistic regression analysis, adhering to pharmacotherapy
increased the odds of being a quitter at 1 and 6 months after quit date (QD), whereas completing behavioral counseling increased
the odds of being a quitter at 1, 6, and 12 months after QD. Point prevalence abstinence at 1 month and prolonged abstinence at
6 and 12 months after QD were 42.2%, 32.6%, and 24.4%, respectively. The overall relapse rate reached 62.5%. Facilitators and
barriers fell under three subthemes: (1) participant factors; (2) provider factors; and (3) system factors. The most common barriers
for non-compliance to the program were stress factors, nicotine addiction, accessibility and availability of pharmacotherapy, cost of
the program and medications, and time restrictions. Conclusion: Adherence to pharmacotherapy and receiving behavioral counseling
increase the odds of smoking abstinence maintenance. Success or failed cessation is influenced by several underlying factors operating
on multiple levels and understanding them might help improve tobacco cessation interventions.

Background: Intraoral polishing of zirconia surfaces had led to a significant increase in the surface smoothness and flexural
strength of zirconia after surface modifications in the try-in procedure; this is a straightforward procedure and does not need
any laboratory interventions. Objectives: The aim of this study was to evaluate the effect of different surface treatments on
yttrium-stabilized zirconia restorations. Materials and Methods: In this study, 36 disk-shaped specimens from zirconia blocks
were milled using a CAD-CAM machine with 12 mm diameter and 1.4 mm thickness for 27 disks; however, 12 mm diameter and
1.2 mm thickness were used for nine disks as a control group. They were sintered and glazed according to the manufacturer’s
instructions. The control group (GA) remained untouched, whereas the other specimens were ground with a diamond rotary
instrument. The final dimension was 12 mm in diameter and 1.2 ± 0.1 mm in thickness. The disks were divided into three groups:
Grinded group (GB) without any additional surface treatment; reglazed group (GC) by adding glaze material; and polished
group (GD), polished with an intraoral polishing kit. The specimens were subjected to a biaxial flexural strength (BFS) test.
Data were statistically analyzed using one-way analysis of variance and least significant difference (LSD) significant difference
tests (a = 0.05). Results: Descriptive statistics shows that the highest BFS was recorded for the GD followed by GB, and both
GA and GC show nearly similar values. The LSD tests revealed that there was a statistically significant difference between GD
and GA (P < 0.05), GD had significantly increased the BFS value after being polished compared with other groups, and there
was a statistically significant difference between GB and GA (P < 0.05). However, there was no statistically significant difference
between GC and GA (P = 0.494). Conclusion: Grinding and polishing techniques significantly increased the flexural strength of
full-contoured zirconia, whereas reglazing significantly decreased it.

Background: Diabetes mellitus is a serious progressive condition associated with multisystemic involvement with a number of chronic
complications due to macrovascular and microvascular damage. Pulmonary involvement is not studied extensively and is not explained
by factors that influence lung function. Objective: The aim of this article is to study the effects of type 2 diabetes on lung function
and delineate the association between lung function impairment and duration of the disease. Materials and Methods: This crosssectional
study was conducted in Baghdad Teaching Hospital. Ninety-one (91) type 2 diabetics with 56 control subjects were included
in this study between March 2020 and June 2021. Both groups are matched by age, sex, height, and weight and are met with exclusion
criteria. Spirometry was done on an electronic spirometer (videography U.K. 1982) for both groups with the following parameters:
forced vital capacity (FVC), force expiratory volume in 1 s (FEV1), FEV1/FVC, and peak expiratory flow rate (PEFR). Statistical
methods compared the results. Results: Type 2 diabetic patients show a significant reduction in FVC, FEV1, and PEFR relative to
their matched controls (P < 0.05). However, there was no significant change in the FEV1/FVC ratio between the groups, meaning a
restrictive pattern in diabetic patients. Conclusion: This study showed that type 2 diabetics had impaired lung function as evidenced
by reduced FVC, FEV1, and PEFR as part of chronic complications of diabetes and showed a progressive decline in parameter with
increased duration of the disease.

Background: Chronic myeloid leukemia (CML) is a clonal myeloproliferative neoplasm that is characterized by the presence of
the Philadelphia (Ph) chromosome, which results from a reciprocal translocation between the breakpoint cluster region (BCR) of
chromosome 22 and the Abelson homolog 1 (ABL1) region of chromosome 9. Programmed death-ligand 1 (PD-L1; also known as B7
homolog 1 and CD274) is an immune checkpoint protein, and its engagement with programmed cell death protein-1 (PD-1) receptor
on T cells activates co-inhibitory signaling to suppress the function of cytotoxic T lymphocytes (CTLs). Interleukin-2 receptor (IL-
2R, CD25) expression is a soluble form of the a-chain of IL-2R (sIL-2R). The IL-2/IL-2 receptor α (IL-2RA) signaling pathway is
essential for the regulation of immune responses. Objective: To assess the plasma level of PDL-1 and CD25 in patients with CML
and their correlations with response to the first line of therapy, tyrosine kinase inhibitor (imatinib). Materials and Methods: This
case-control study was conducted on 66 patients with CML in the chronic phase (CP) from May 2019 to October 2019. The patients
were sequentially selected and subdivided into three subgroups: 20 new diagnoses before starting treatment, 30 imatinib therapy
responders, and 16 imatinib resistant for each group. Plasma samples were tested for the levels of PD-L1 and CD25 by the enzymelinked
immunosorbent assay technique. Results: Programmed cell death ligands were significantly increased in the plasma of patients
with CML compared with the control group, and there was a significant increase in the plasma PD-L1 of patients with a new diagnosis
compared with imatinib responders and patients who were resistant. There was no significant difference in PD-L1 level between the
responder and resistant groups. Soluble CD25 was significantly increased in the plasma of patients with CML compared with the
control group, and there was a significant increase in the plasma CD25 of patients with a new diagnosis compared with imatinib
responders and patients who were resistant. There was no significant difference in CD25 level between responder and resistant groups.
Conclusion: Plasma PD-L1 and CD25 levels were significantly higher in adult patients with CML compared with healthy subjects,
and these levels were significantly higher in patients with CML who are newly diagnosed compared with imatinib therapy responders
and resistant counterparts. There is no significant difference between responders and resistant groups in regard to PD-L1 and CD25.

Background: Type 2 diabetes usually starts with insulin resistance—a condition that happens when muscle, fat, and liver cells cannot
use insulin to deliver glucose into the cells of the body for energy use. Materials and Methods: The group subjected to this study consists
of 45 type 2 diabetic patients whose age ranges from 30 to 55 years, from both sexes (22 males and 23 females); the control group also
includes 45 apparently healthy persons, and they were free from symptoms and signs of any diseases and ages of this group ranged
between 30 and 55 years, from both sexes (23 females and 22 males). Protein kinase A (PKA) and G-glycoprotein concentrations
was determined by Sandwich-ELISA kits by Sunlong (China) Company. Results: The results of this study revealed no significant
differences in the concentration of PKA between patients and control groups, that is, PKA level of female patients and its control and
of male patients and its control and between type 2 diabetes mellitus (T2DM) male and T2DM female (P > 0.05). Also, the results
of the study revealed that there were no significant differences in the concentration of P-glycoprotein (PGP) between patient and
control groups, T2DM females and T2DM males, and between T2DM male and its control group (P > 0.05), except for that between
female T2DM and its control; the results revealed that there was a significant difference in the PGP concentration (P < 0.05). Finally,
a moderate significant positive correlation was found between PKA and PGP concentrations (P = 0.000, r=0.51). Conclusion: In our
study, we measure the actual PKA concentration; it is important for future studies to measure PKA activity instead of concentration
to find the role of active PKA in glucose hemostasis. Also, the study of G-glycoprotein gene expression, instead of concentration, is
used to explore the accurate function of G-glycoprotein in the distribution and clearance of anti-diabetic drugs.

Background: Thalassemia is an inherited disorder of hemoglobin (Hb) synthesis that results in reduced or absent production of
globin chain. Hypercoagulable state in thalassemia is a well-recognized event. Thrombin activatable fibrinolysis inhibitor (TAFI) is
an enzyme considered to play an important role in the regulation of fibrinolysis by the coagulation system. With this background,
the present study was conducted to know the role of TAFI as a contributing factor in hemostatic alteration state in adults with
β-thalassemia. Aim: The aim of this article is to evaluate the level of TAFI and hematological parameters in splenectomized and nonsplenectomized
β-thalassemia patients and to compare their levels with normal subjects. Materials and Methods: This case–control
study was conducted in 56 adult thalassemic patients. The plasma TAFI level was evaluated by the ELISA technique. Results: There
was a significant reduction in TAFI levels in all thalassemic patients when compared with thalassemia minor patients and controls
(P < 0.0001). The TAFI level was significantly lower in the splenectomized group when compared with the non-splenectomized
group (P < 0.0001), and the TAFI level was significantly lower in the thalassemia major group when compared with the thalassemia
intermediate group (P < 0.0001). There was a significantly higher prothrombin time and activated partial thromboplastin time level
in thalassemic major and intermediate patients when compared with thalassemia minor patients and controls (P < 0.001). Conclusion:
The TAFI enzyme level could be an important predictor for hemostatic alteration. Its level can be considered as a

Background: Vegetables are essential for the human body and they constitute the main daily consumed diet. However, vegetable
consumption is one of the main routes of transmission of intestinal parasites in humans. Objective: This study aimed to investigate
parasites that caused vegetable contamination in Duhok city, Kurdistan region of Iraq. Materials and Methods: In the current study,
from June 2021 through August 2021, a total of 166 samples of fresh vegetables were collected from several markets in different places
of Duhok city. Samples were examined microscopically for parasitic investigation. Results: It was shown that 10.2% of vegetables were
contaminated with parasites, but with no significant margin between contaminated and non-contaminated vegetables (P value = 0.81).
The parasitic contamination was detected in lettuce (15%), parsley (14.3%), and radish (14.3%), with no parasitic contamination in both
carrot and cucumber. Three types of parasites were detected in vegetable samples; they were in the order of 5.4% for Entamoeba spp.,
4.2% Giardia lamblia, and 1.2% Balantidium coli. Conclusion: In conclusion, the present study identified fresh vegetable contamination
with protozoan parasites in moderate rate, which can play an important role in the transmission of pathogenic intestinal parasites.

Background: Self-medication with antibiotics (AB) is an ongoing main global health problem. It is defined as the use of nonprescribed
medications by people on their own initiative or on the advice of another individual, without physician consultation. Lack of knowledge
among parents regarding the prudent use of AB in managing common childhood illnesses can result in its misuse. On the other hand,
physicians commonly prescribe AB as their first response for several symptoms, usually relating such over-prescription to patients’/
parents’ pressure. Although AB are targeted to kill or inhibit the growth of bacteria and have no effect on viral agents, it is often
inappropriately used to treat viral infections, such as most upper respiratory tract infections (URTI). Problems associated with the
overuse of AB include development of antibacterial resistance, increasing the burden of chronic diseases, rising costs of health services.
Objectives: To evaluate mothers’ Knowledge, Attitudes, and Practices (KAP) related to antibiotic use for children with URTI in a sample
of mothers in Babylon Governorate and assess the associated factors with antibiotic misuse among mothers who attended primary
healthcare centers and hospitals. Materials and Methods: A cross-sectional study was carried out in Babylon Governorate during the
period from April 10 to June 20, 2021. Two primary healthcare centers (one in the periphery of Babylon Governorate and the other in
center of Babylon Governorate) and two hospitals (one in the periphery of Babylon Governorate and the other in center of Babylon
Governorate) were selected conveniently and 270 mothers who attended these centers interviewed 3–4 days per week during the period
of the study. Data were gathered through structured questionnaire that was used to identify different variables in the study during the
interview. Statistical analysis was carried out using Statistical Package for the Social Sciences. Results: The mean age of mothers was
(30 ± 7) years old. Small percentage had adequate knowledge about antibiotic use (26.3%), and only 8.52% had positive attitudes.
Also, only 10.37% had good practice. Self-medication of AB was in a large proportion of mothers (67%) and most of them depend
on pharmacists as a source of information (61.24%). There was a significant association between inadequate knowledge and mothers
who were housewives, school-educated, and had self-medication practice. There was a significant association between negative attitude
and poor practice with mothers who had self-medication. This study revealed that mothers who lived in rural areas, school-educated,
housewives, and had enough monthly income tend to self-medicate their children with AB. Conclusions: Inadequate knowledge related to
mothers with school education and housewives. Self-medication with AB is related to poor KAP. Self-medication occurs mostly among
mothers who are housewives, residents in rural area, had school education, and have enough income.

Objectives: The aim of this article is to evaluate attitude among dental practitioners in Erbil/Iraq toward the use of hand and rotary
endodontic instruments and to evaluate whether there is any relation regarding the preference in using a specific type of instrument
with the level of specialization and clinical practice when performing root canal treatments (RCTs). Materials and Methods: It was
a cross-sectional questionnaire study conducted in Erbil, Iraq. A total of 111 dentists participated in this study; data regarding
the information about demographic details of dental professionals, years of experience, and number of RCTs done per week by
dental professionals were obtained. The use of rotary and hand instruments by dental professionals was inquired. Procedural
problems with rotary instruments faced by dental professionals and reasons for not using the rotary instruments if any were also
recorded. The data were submitted to descriptive analysis, and associations were tested with χ2 test and Fisher’s exact test using
SPSS software version 23. P-value was set as <0.05. Results: Forty-four (39.6%) of the total study samples used both rotary and
hand instruments, whereas 25 (22.5%) of them used only rotary instruments for RCTs. Dentists who were using rotary instruments
are facing the procedural problems of file fracture [74 (66.7%)] and those dental professionals using hand instruments are facing
the procedural problems of ledge formations [55 (49.5%)]. There was no significant relationship between using a specific type of
instrument and the level of specializations (P = 0.941). Conclusion: In conclusion, the results of this study showed that dentists
preferred using both rotary and hand endodontic instruments for RCTs with no significant relation with the level of specialization
regarding using specific types of instruments, and dentists experienced some procedure errors regarding both types of instruments
while using them for RCTs.

Background: Diabetes and other chronic diseases can affect linear growth and pubertal development. Poor glucose control, long
duration, and younger age at onset negatively affect growth and pubertal development. Objectives: This study was designed to describe
height, body mass index, and sexual maturation of Iraqi type 1 diabetic adolescents, and their relation to the age at diagnosis, duration
of disease, and insulin dose. Materials and Methods: Seventy type 1 diabetic patients were involved in this cross-sectional study. Their
ages ranged between 10 and 18 years with diabetes for more than 2 years. Height, weight, body mass index, and pubertal stage were
assessed. Then they were correlated with insulin dose, age at diagnosis, and duration of diabetes. Results: There was no significant
difference between male and female mean height Z score, whereas the mean body mass index Z score was significantly higher for
females than for males. Most of the patients had normal height and body mass index, and only 14.3% and 4.3% were short and
underweight, respectively, and there was a significant inverse correlation between duration of diabetes and height SD. Twenty-seven
females had menarche. Its age ranged from 10 to 16 years, with a mean of 13.5 ± 1.44 years. Three males and three females (8.6%)
had delayed puberty, and no patient had precocious, with a significant positive correlation between pubertal development and height
SD. Conclusion: Although there is an improvement in growth parameters for Iraqi diabetic children, they are still abnormal, especially
with long diabetes duration.

Faculty development programs (FDPs) occupy an important role in the effective delivery of the medical curriculum to the medical
students. Owing to the specific recommendation by the regulatory body, all the medical colleges are conducting a specific number of
mandatory FDPs. However, like any other program, the mere organization of any FDP does not serve the purpose, unless the quality
assurance of such programs is ensured and the outcomes of the same are evaluated as a follow-up activity. The quality assurance of
the FDP can be assessed via either the internal or external quality assurance methods. In conclusion, the FDPs play a crucial role in
improving the competence level of the faculty members. However, in order to ensure that we accomplish the set targets, it is extremely
essential to maintain the quality of the organized FDPs and follow it up in the subsequent period.

Dear Editor,
The debate on the efficacy of chloroquine (CQ) and
hydroxychloroquine (HCQ) in the present severe
acute respiratory syndrome coronavirus 2 (SARS
COV-2) pandemic is still raging. Nevertheless, many
organizations, politicians, and health-care professionals
have propagated their use in prophylaxis and treatment
of the infection resulting in many patients self-medicating
and an increase in the demand for these drugs globally.
Both these drugs are derivative of quinine, which is
already known to be ototoxic.[1] Although there are no
randomized trials, a substantial number of reports exist
in the literature regarding the ototoxic potential of
these drugs.
The ototoxicity

Mupirocin (MUP) is a natural derivative of crotonic acid extracted from Pseudomonas fluorescens. This antibiotic has a unique
chemical structure and mechanism of action.
It is often used topically for the treatment of cutaneous infections to prevent skin and soft tissue infections caused by S. aureus isolates
and where the MRSA isolates are epidemic. Furthermore, MUP may be used as a choice drug for nasal decolonization.
Despite some side effects, mupiro¬cin has been reported to be safe and to cause allergic reactions in only extremely rare cases. This
paper is a report on a rare case of severe systemic allergic reaction resulting from treatment with mupirocin ointment in a 39 year old
male patient who had a history of burn injury.

Dengue fever (DF) is a common mosquito-borne viral illness, with various cardiovascular implications, including electrocardiographic
abnormalities, due to profound myocardial involvement (myocarditis) by the dengue virus. Here, we are describing an untraditional
presentation of DF, in which a young male encountered with cardiac rhythm abnormalities without fever, thrombocytopenia, or
capillary leakage. The patient had symptomatic hypotension, and his electrocardiogram (ECG) demonstrated alternative patterns
of ventricular bigeminy and trigeminy. Serum electrolytes, total leukocyte counts, and renal function tests were normal, but cardiac
biomarkers were elevated in this patient. Two-dimensional echocardiography demonstrated global left ventricular wall hypokinesia with
an ejection fraction of 53%, but the coronary angiography indicated no vascular thrombus or occlusion. Subsequent evaluation found
that the dengue IgM antibody by enzyme-linked immunosorbent assay was positive in this patient. He was managed conservatively for
this and had a splendid recovery in the form of normal ECG at the time of discharge and echocardiography on follow-up. The case
delineates a rare and challenging presentation of cardiac involvement in DF.